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Therapeutics V > Superficial and Invasive Fungal Infections > Flashcards

Superficial and Invasive Fungal Infections Flashcards

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1
Q

Most common causes of fungal infections

A

Aspergillus, candida and pneumocystis

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2
Q

Most common Candida (oropharyngeal, OPC, and esophageal, EC)

A

Candida albicans

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3
Q

Candidiasis is an ______________ infection

A

opportunistic infection

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4
Q

Candidiasis is what type of immunity

A

cell-mediated (mediated by CD4 T-cells)

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5
Q

OPC & EC Risk Factors (local)

A

-Use of steroids (suppress cellular immunity) and
antibiotics (alteration of endogenous oral flora)

-Dentures

-Xerostomia due to drugs, chemotherapy,
radiotherapy to head/neck, BMT

-Smoking

-Disruption of oral mucosa caused by chemotherapy
and radiotherapy, ulcers, endotracheal intubation
trauma, burns

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6
Q

OPC Clinical presentation

A

“cottage cheese appearance”

yellow-ish white

scrapes off easily

dysphagia (difficulty swallowing)

odynophagia (pain on swallowing)

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7
Q

OPC & EC Risk Factors (systemic)

A

-Drugs (e.g., cytotoxic agents, corticosteroids,
immunosuppressants after organ transplantation,
PPIs)

-Neonates or elderly

  • HIV infection/AIDS
  • **Depletion of CD4 T-lymphocytes
  • **HIV viral load
  • Diabetes
  • Malignancies (e.g., leukemia, head/neck cancers)
  • Nutritional deficiencies
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8
Q

OPC treatment range

A

7 - 14 days

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9
Q

OPC: mild infection

A

topical

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10
Q

OPC: MILD tx options (3)

A

-Clotrimazole 10 mg troche (hold in mouth for 15-20
minutes for slow dissolution) 5x/day

-Nystatin 100,000 units/ml suspension, 5 mL swish and
swallow, QID

  • Miconazole 50 mg mucoadhesive buccal tablet, apply to upper gum region (canine fossa) daily x 7-14 days
  • **Apply in morning after brushing teeth; hold in place 30 seconds to ensure adhesion; gradually dissolves
  • **Eat and drink normally but avoid chewing gum
  • **If falls off & swallowed in first 6 hours, apply new tablet
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11
Q

OPC: Mild

WHY WOULD USE SYSTEMIC THERAPY

A

Systemic therapy needed in patients with
refractory OPC, patients who cannot tolerate
topical agents, patients with moderate to severe
disease, and patients at high-risk for
disseminated systemic disease (neutropenia)

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12
Q

OPC Mild systemic therapy

A

*Fluconazole (most common) 100-200 mg daily (preferred)

  • Itraconazole solution 200 mg daily
  • **Take on empty stomach

-Posaconazole suspension 100 mg BID on day 1, then
100 mg daily x 14 days (with food)

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13
Q

OPC Mild systemic therapy IF REFRACTORY, how long treat

A

> /= 14 days

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14
Q

OPC Mild systemic therapy refractory treatment options

A

(options if can’t use fluconazole)

  • Itraconazole solution 200 mg daily
  • Posaconazole suspension 400 mg BID x 3 days, then 400 mg
    daily for 28 days
  • Amphotericin B deoxycholate suspension (100 mg/mL) 1-5 mL
    swish & swallow QID
  • Voriconazole 200 mg BID (> 40 kg)
  • Caspofungin 70 mg LD, then 50 mg IV daily
  • Micafungin 150 mg IV daily
  • Anidulafungin 200 mg IV daily
    • Amphotericin B deoxycholate 0.3-0.7 mg/kg/day
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15
Q

EC candidiasis tx length of time

A

14 - 21 days

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16
Q

EC candidiasis tx options

A

Systemic therapy always required

• Fluconazole 200-400 mg PO/IV daily
• Itraconazole solution 200 mg PO daily
• Echinocandin (micafungin 150 mg daily; caspofungin 70 mg
LD, then 50 mg daily; anidulafungin 200 mg daily)
• Voriconazole 200 mg PO/IV BID (> 40 kg)
• Posaconazole suspension 400 mg PO BID or delayed release
tablets 300 mg daily
• Amphotericin B deoxycholate 0.3-0.7 mg/kg/day

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17
Q

For EC candidiasis, always

A

SYSTEMIC THERAPY

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18
Q

EC candidiasis refractory

A
  • Fluconazole-refractory – treat for 21-28 days
  • Itraconazole solution 200 mg PO daily
  • Posaconazole suspension 400 mg PO BID (with food)
  • Voriconazole 200 mg PO/IV BID (> 40 kg)

• Amphotericin B deoxycholate 0.3-0.7 mg/kg/day or
lipid-based formulation 3-5 mg/kg/day

  • Caspofungin 50 mg IV daily
  • Micafungin 150 mg IV daily
  • Anidulafungin 100 mg IV on day 1, then 50 mg IV daily
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19
Q

vulvovaginal candidiasis (VVC): complicated vs uncomplicated

A
  • Uncomplicated: sporadic infection that is susceptible to all
    forms of antifungal therapy regardless of treatment duration
  • Complicated: recurrent VVC; severe disease; non-Candida
    albicans infection; host factors (DM, immunosuppression,
    pregnancy)
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20
Q

VVC most common pathogen

A

Candida albicans

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21
Q

VVC non-c albicans, next most common

A

C. glabrata most common

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22
Q

If female complains of burning…

A

ask more questions regarding infection

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23
Q

pseudohyphae

A

THINK CANDIDA, THEN THINK SEGMENTED OR NON-SEGMENTED

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24
Q

VVC tx topical vs oral

A

topical // oral = cure rates are similar

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25
VVC tx duration
***duration not critical -Similar cure rates despite different lengths of therapy -Shorter durations (e.g., 1 day) have higher drug concentrations that maintain therapeutic effect for 72 hours
26
Uncomplicated VVC tx (OTC/topical vaginal products)
- Butoconazole 2% cream, 1 applicator x 3 days - Clotrimazole * **1%, 2%, 10% cream, 1 applicator x 1 day * **100 mg tablet, 1 tablet x 7 days * **200 mg tablet, 1 tablet x 3 days * **500 mg tablet, 1 tablet x 1 day - Miconazole * **2% cream, 1 applicator x 1 day * **100 mg suppository, 1 suppository x 7 days * **200 mg suppository, 1 suppository x 3 days * **1200 mg ovule, 1 ovule x 1 day -Tioconazole 6.5% cream, 1 applicator x 1 day • Prescription/topical -Nystatin 100,000 units tablet, 1 tablet x 14 days (FIX THIS) - Terconazole * **0.4% cream, 1 applicator HS x 7 days * **0.8% cream, 1 applicator HS x 3 days * **80 mg suppository, 1 suppository HS x 3 days
27
Uncomplicated Prescription/oral
- Fluconazole 150 mg tablet, 1 tablet PO x 1 day | - Ibrexafungerp 300 mg PO twice daily x 1 day
28
GO BACK AND REDO TX SLIDES
GO BACK AND REDO TX SLIDES
29
How is boric acid given?
GIVE INTRAVAGINALLY
30
Tinea capitis
More common in children
31
Define prophylaxis
pt not infected, want to prevent from getting infected
32
Histoplasmosis onset
specific T-cell immunity in non-immune host
33
What is a granuloma?
area of tissue inflammation due to a collection of immune cells; form when immune system attempts to wall off foreign substances but can’t eliminate it (need functional T-cells to form this)
34
Histoplasmosis Clinical Presentation: Disseminated histoplasmosis
May be seen in patients exposed to large inoculum or in immunocompromised host (especially if decreased ***cell-mediated immunity)
35
Histoplasmosis Diagnosis
``` Serologic testing – detect Histoplasma antigen (blood, urine, BAL) - Complement fixation - Immunodiffusion - Latex agglutination ```
36
``` HISTOPLASMOSIS TREATMENT – IMMUNOCOMPETENT HOST (can cause disease in a NORMAL host) ```
most of the time asymptomatic
37
What is the DRUG OF CHOICE histoplasmosis? (FOR MILD TO MODERATE)
FUCKING itraconazole (weeks for duration of therapy) also keep in mind subaitraconazole also think about tablet and capsule formulations
38
What is the DRUG OF CHOICE histoplasmosis? (FOR MODERATE TO SEVERE)
lipid amphotericin B deoxycholate
39
How to differentiate between mild-moderate and moderate to severe histoplasmosis disease?
Disease severity
40
``` HISTOPLASMOSIS TREATMENT – IMMUNOCOMPROMISED HOST (can cause disease in a NORMAL host) ```
Re listen to his comments
41
clarify tx durations for immunocompetent vs immunnocompromised
ugh
42
if case of pt in arizona or new mexico, what is the organism
coccidioimycosis coccidioides immitis
43
if see diffuse maculopapular rash
think coccidioimycosis
44
go back and match states/region to pathogen
i.e. histo = indiana
45
cryptococcosis what type of immunity
cell-mediated immunity
46
flucytosine SE
bone marrow suppression
47
candida loves what
FUCKING PLASTIC
48
CANDIDIASIS/CANDIDEMIA | PATHOPHYSIOLOGY/CLINICAL PRESENTATION: What plays a major role?
PMNs (polymorphonuclear i.e. neutrophils, eosinophils, basophils) play a major role in patient’s host defense
49
Would use voriconazole for candidemia in nonneutropenic adults?
no we got other stuff
50
For candidemia, clock doesn't start
until there is a negative blood culture. That day is day one********** (double check this)
51
CANDIDEMIA – TREATMENT | NEUTROPENIC ADULTS: C. glabrata
echinocandin preferred
52
If C. krusei – echinocandin, lipid amphotericin B, | or voriconazole preferred
DO NOT FUCKING USE FLUCONAZOLE
53
CANDIDEMIA – TREATMENT | NEUTROPENIC ADULTS: C. parapsilosis
fluconazole or lipid | amphotericin B preferred
54
Do NOT treat candida
from a sputum culture
55
How long treat candida?
Treat for 14 days after documented clearance of Candida from blood, resolution of symptoms, and resolution of neutropenia NEED PATHOLOGIC EVIDENCE OF CONTAMINATION
56
Do you treat asymptomatic candiduria?
FUCKING NO
57
WHAT GETS INTO THE URINE?
FLUCONAZOLE AND FLUCYTOSINE
58
ASPERGILLOSIS MOST COMMON PATHOGEN
A. fumigatus
59
ASPERGILLIUS...DONT USE
AMPHOTERICIN
60
_____________ is the most important predisposing factor to the development of invasive aspergillosis
PROLONGED NEUTROPENIA
61
ASPERGILLOSIS | CLINICAL PRESENTATION most common site
lung
62
if see halo sign on ct think
aspergillus

Therapeutics V (17 decks)

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